Using a Theory-based SMS/VM Intervention to Improve Sexual and Reproductive Health of Female Entertainment Workers in Cambodia: Study Protocol of a Randomized Controlled Trial

Introduction

Mobile phones are increasingly being used to enhance the effectiveness of health programs by engaging individuals in discreet and ongoing ways. Mobile phone health interventions, called mHealth, can also improve the availability and quality of operational research data. mHealth interventions have successfully been used in developing countries to collect health data, increase access to health knowledge and increase medication/appointment adherence. But, few mHealth interventions have been rigorously evaluated. There is strong evidence that mobile phone messages can be successfully used to support preventative healthcare, such as maternal postpartum visit attendance in Kenya. There is also evidence that self-report of risk behaviors through a mobile phone is a method of data collection that is as reliable and valid as in-person surveys. Especially for mobile or hidden populations in developing countries, mobile phones may become our most important tool for linking people to health services.

In Cambodia, several successful mobile phone-based health programs have been introduced in the areas of post-abortion contraceptive use, pharmacovigilence, diabetes self-management, case detection/notification and HIV education. The current evidence base for mobile phones used for health assessment and encouragement of the uptake of services, especially for hard-to-reach populations that face stigma and discrimination in developing countries is promising, but stronger impact evaluations are needed to understand the full benefits of such interventions.

One important hard-to-reach, high-risk group in Cambodia is the growing population of female entertainment workers (FEWs). FEWs are women working in entertainment venues such as karaoke bars, massage parlors, restaurants (as hostesses or singers) or beer gardens. FEWs frequently sell sex, directly or indirectly, to male patrons to supplement their income. By 2013, there were approximately 40,000 FEWs in Cambodia, 24,000 of whom resided in the capital city of Phnom Penh. This group has been increasing since the 2008 passage and implementation of the 'Law on Suppression of Human Trafficking and Sexual Exploitation,' which banned brothel-based sex work, and more women have moved into indirect sex work based out of entertainment venues.

The influx in the number of FEWs also follows the increase in garment factory jobs that attract young women from poor rural families to migrate to urban areas to earn and remit income to their families in their home villages. Today, the garment factories in Cambodia employ over 700,000 young women. Garment workers are typically not given fair wages, safe work environments or health insurance-a combination of factors that have resulted in worker unrests and mass fainting incidents at various factories. Claiming worker rights becomes a complicated challenge that involves risking their jobs, their livelihood and their ability to provide for family. As a result, more and more young migrant women become involved in alternative work opportunities in the entertainment industry. In addition, urban youth may also be at-risk of engaging in sex work. A recent study from Cambodia found that 48% of at-risk female youth across the country reported having been paid for sex in the past year.